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Galore International Journal of Health Sciences and Research Vol.4; Issue: 2; April-June 2019 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321

Treatment of : A Review

Dr. Divyanshu Jamwal1, Dr. Ketaki Kanade1, Dr. Vivek Singh Tanwar1, Dr. Pramod Waghmare2, Dr. Nilima Landge3

1PG student, 2Professor, 3Associate Professor, Bharati Vidyapeeth Dental College and Hospital, Pune.

Corresponding Author: Dr. Divyanshu Jamwal

ABSTRACT phonetics problems and food accumulation. [1-3] In the absence of contact point, the color Current dentistry involves both functional and disappears leading to black, pyramidal esthetics role. and loss of shape formation. [4] Apart from its Interdental papilla results in Gingival Black functional role, increasing public demand Triangle, which is esthetically unpleasing. for esthetics, place huge pressure on modern Interdental papilla loss is strongly associated with increasing age, periodontal diseases and clinical dentistry to restore any lost ‘white’ post orthodontic treatment. To achieve and ‘pink’ esthetics. White esthetics denotes reconstruction of the lost interdental papilla is natural teeth and pink refers to gingival difficult and challenging, as it is associated with tissues surrounding the teeth. Balance the patient smile and esthetics. Absence of between soft and teeth adjacent to it interdental papilla raises concern over phonetic with minimal or no tissue deficiencies is key problems, food and plaque accumulation, which for stable . further deteriorates the present condition along The main objective of periodontal with esthetic problems. Various treatment therapy is ‘prevention of progression of options for papilla loss are present which periodontal disease and associated trauma involves non-surgical approach (oral hygiene by regeneration of the lost periodontal procedures), prosthetic restorations and surgical [5-7] procedure for increasing tissue volume. The tissues’. Though several surgical present review discusses the different techniques have been constantly proposed classifications of papilla loss, etiology and experimented, they are mostly invasive [8] associated with open gingival embrasures and and unpredictable. Moreover, the success all currently available nonsurgical and surgical rate of surgical augmentation of papilla treatment modalities recommended for papilla relies on the thickness of gingiva biotype. [9] preservation and reconstruction. Hence, a number of nonsurgical, minimally invasive techniques have been developed to Keywords- Interdental Papilla, papilla preserve and restore interdental papilla. preservation, papilla reconstruction, papilla Though many solutions have been proposed regeneration, black triangle. to correct lost interdental tissues, no golden

standard technique is followed so far due to INTRODUCTION the absence of long-term clinical results and Interdental papilla represents a small predictability. The present review discusses visible area present in-between teeth and the various classifications of papilla loss, gingiva of the oral cavity. Interdental papilla etiology associated with Gingival Black plays an important role in esthetics due to its Triangle and currently available nonsurgical strong association with the patient smile. and surgical treatment modalities Gingival black triangle (GBT) is a cosmetic recommended for papilla preservation and deformity which refers to an absence of reconstruction. papilla resulting in black spaces or open embrasures which impairs esthetic features,

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Anatomy of interdental papilla equal to 5mm in 56% of cases and in which The interdental papilla is defined as the distance was 6mm, and only 27% of the gingival tissue extending from the cases in which the distance was 7mm or incisal tip of the papilla to a line tangential more. [12] According to Fradeani, the to the gingival margins of the two adjacent distance between the roots is another factor teeth. Interdental papillae are the extensions that can influence the presence or absence of gingiva filling the spaces between of interdental papilla. The author stated that adjacent teeth. It is formed by dense the inter-radicular distance smaller than connective tissue covered by epithelium and 0.3mm jeopardizes the presence of the is influenced by the height of alveolar bone, proximal bone and, therefore, it is usually the distance between the teeth and the accompanied by the lack of interdental interdental contact point. [10] Because the papilla. [13] mass bordering the interdental papilla is less in anterior teeth, the interdental CLASSIFICATION OF INTERDENTAL papilla is narrow and has a pyramidal shape PAPILLA LOSS and its tip just below the contact point. In Nordland and Tarnow (1998) posterior teeth, due to the presence of larger proposed a classification system regarding tooth mass, it is wider and with a ridge the papillary height adjacent to natural teeth, shaped concaved area called as ‘col’. [11] based on three anatomical landmarks- The In the anterior teeth, the location of interdental contact point, the apical extent of the contact point varies. For example, the the facial (CEJ), contact point between two central is and the coronal extent of the proximal CEJ located at the incisal third of the labial [14] (Fig 1) aspect. The contact point between central Normal: Interdental papilla fills occupies and lateral , is located at the incisal the entire embrasure space apical to the third. It can be said that interdental papilla interdental contact point/area. between two central incisors is filled with Class I: Tip of interdental papilla is located more space than the other teeth in anterior between the interdental contact point and region. the level of the CEJ on the proximal surface A classical study conducted by of the tooth. Tarnow et al. studied the presence or Class II: Tip of interdental papilla is located absence of interdental papilla with the at or apical to the level of the CEJ on the distance between the bone crest and the proximal surface of the tooth but coronal to contact point in 30 patients. The presence of the level of CEJ mid buccally. the papilla was observed in 100% of the Class III: Tip of interdental papilla lies level cases in which the distance was less than or with or apical to facial CEJ.

Fig1- Classification by Norland and Tornow [14]

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The Papilla Presence Index (PPI) ligament causing recession, loss if (Cardaropoli et al., 2004) [15] interproximal bone height in relation to A New System to Assess Interproximal interproximal contact, angulation of roots Papillary Levels – proposed by Cardropoli and presence of crowns. Active periodontal et al. (2004) diseases are associated with loss of • PPI score 1 - Papilla completely present interdental papilla. Periodontal pockets with • PPI score 2 - Apical to contact point probing depth more than 3mm will lead to • PPI score 3 - Apical and CEJ visible an increase in plaque retention, • PPI score 4 - Apical to both CEJ. inflammation and recession. As the resorption of alveolar crest progresses, the Nemcovsky introduced a classification distance between the contact point and the system as a papillae index score (PIS) based alveolar bone crest increases, resulting in on a comparison with adjacent teeth: [16] (Fig loss of interdental papilla. 2) PIS 0: Papilla not present and no curvature Factors influencing the presence of of the soft tissue contour. interdental papilla are [Etiology (Fig 3)] PIS 1: Present papillae height less than half Underlying osseous architecture the height of the papilla in the proximal The shape and form of interdental teeth and a convex curvature of the soft papilla depends upon underlying bone and tissue contour. its architecture. In general, the positive PIS 2: Presence of at least half the height of architecture refers to the osseous crest, the papilla in the proximal teeth, but not in which follows the shape on cement-enamel complete harmony with the interdental junctions, and the position of the papilla of the proximal teeth. interproximal bone is commonly coronal PIS 3: Papillae able to fill the interproximal than the radicular bone; is most commonly embrasure to the same level as in the associated with interdental papilla. The proximal teeth and in complete harmony distance of the contact point to the alveolar with the adjacent papillae. crest is an important factor determining the shape and form of papilla. According to Tarnow et al (1992) when distance from the contact point to the alveolar crest was less than or equal to 5mm, the papilla was present in 98% of the times, while at 6mm it dropped to 56% and at 7mm it was present only 27% of the times. [17] Distance between root surfaces The distance between root surfaces also influence the presence of interdental papilla. In a study, Tal (1984) analyzed the interproximal distance of roots and the Fig 2- Classification by Nemcovsky [16] prevalence of infrabony defects. It was FACTORS THAT DETERMINE THE concluded that the distance between roots PRESENCE OR ABSENCE OF was more than or equal to 3.1mm, two INTERDENTAL PAPILLA: separate infrabony defects were noted. In There are multiple factors which other words, we can say that a minimum of 3mm interdental distance may be needed in determine the presence or absence of [18] interdental papilla. These factors include maintaining papilla. changes in tooth alignment during Periodontal biotype orthodontic treatment, loss of periodontal

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There are two morphological forms there is complete fill of gingival embrasures of interdental papilla and the osseous with interdental papilla. For every 1mm architecture, the thin and thick periodontal above 5mm, the chance of complete fill is biotype. In general, thick biotype is better reduced by 50%. For square shaped teeth than thin biotype for the presence of with wide contact points, the chances of interdental papilla. Thin biotype has fragile black triangles; are minimal as compared to that is more susceptible to triangular teeth having narrow, more recession. Thick biotype is fibrotic and incisally positioned contact points. [17] resilient, making it resistant to surgical morphology: procedures with a tendency of pocket The shape of the crown is an formation and recession. The interdental important factor which determines the shape gingival tissue possesses biological tissue and form of interdental papilla. There are 3 memory, due to which under favorable basic crown forms: circular, square and conditions the interdental papilla attains its triangular. The square crown yields better original shape and form. The thick biotype interdental papilla maintenance due to wider is more conducive for the rebound of contact and smaller interproximal distance gingival tissue than thin biotype. [19] from the osseous crest to the contact point. The triangular crown form results in a Periodontal bioforms: pronounced gingival scallop and thin The periodontal bioform denote the underlying crestal bone, which predisposes basic gingival scallop morphologies. 3 types for interdental papilla recession. [19] of gingival scallop morphologies have been described: high, normal and flat. The gingiva scallop morphologies are determined by the underlying bone architecture. For example, in the shallow gingival scallop, the interproximal bone is thin, and the interproximal gingival contour nearly parallel to the underlying bone contour. Flat scallop is better than high scallop for favorable esthetics. This is because, in flat scallop, the bone has a congruous relationship with the free and is less prone to post- surgical recession. The high scallop has wider underlying interproximal one, but due to disparity between the bone contour and free gingival margins the esthetics may be compromised due to formation of black triangles. [20,21] Contact points: Fig 3- Etiology pyramid of gingival black triangle [17-19] The contact point of maxillary anterior teeth and their distance from the TREATMENT crest of the interproximal bone plays a Various non-surgical and surgical important role in the form and shape of techniques have been introduced with the interdental papilla. In a landmark study, sole intension of either reconstruction or Tarnow et al (1992) described the ‘5mm [22-30] regeneration of the lost papilla either by rule’. The rule states that when the modifying the interproximal spaces or by distances from the contact point to the surgical reconstruction of the lost soft tissue interproximal osseous crest is 5mm or less, between the teeth. The non-surgical

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 4 Vol.4; Issue: 2; April-June 2019 Divyanshu Jamwal et.al. Treatment of Interdental Papilla: A Review approach (orthodontic, prosthodontics, hygiene procedures should be initially restorative) modify the interproximal space, discontinued and then successively thereby inducing modifications of the soft modified. Re-epithelialization of the tissues. Most of the surgical procedures traumatic lesion can restore the papilla have emphasized gingival grafting. completely. [31-35] Non-surgical approach: Restorative and Prosthetic Approaches Patients may have one or more Prosthetic approaches include use of etiological factors present, thus, managing porcelain, acrylics, silicone-based soft such patient requires a proper assessment materials or co-polyamide and composite and treatment plan. If the loss of papilla is resin. Composite resin is available in pink related to only soft tissue loss, shades for gingival reproduction and can be reconstruction techniques are used for used on restorations to replace missing soft restoring it completely or if the loss of tissue. Though pink porcelain can mask the papilla is caused by periodontal diseases interdental papilla, porcelain shades and with interproximal bone resorption, usually optical properties are limited. Removable a complete reconstruction is not achieved. acrylic or silicone can be used as a gingival Though several surgical and nonsurgical veneer to camouflage lost gingival tissues treatment options are available, there is no and is indicated only when the interdental golden standard set due to lack of large defects present are with >5mm gap between scale clinical trials or long term clinical contact point and alveolar crest. The outcomes. When compared to surgical removable prosthesis facilitates a larger techniques which are less predictable and volume of tissue replacement without painful, [9] nonsurgical techniques are disturbing other dental units that allows preferred due to their cost effectiveness, less proper cleaning, while the fixed restorations stressful and achieve immediate results with of soft tissue in the esthetic zone, can be high satisfaction rate. Nonsurgical treated by pink porcelain which will recreate approaches include correction of traumatic natural tooth proportions and provide a oral hygiene procedure, restorative realistic alternative to surgery. Maintenance techniques, orthodontic movement, repeated of Hygiene is strongly recommended to scrapping of the papilla and tissue improve the performance of prosthesis. volumizers. Kimand Cho used modified Mylar strip Correction of Traumatic Oral Hygiene technique to close diastema by using direct Procedure composite resin. Though the technique Toothbrush abrasion causes cement adapted was less stressful and economic, and enamel wear and can damage incorrect resin composition may result in supporting gingival tissues leading to wear, fracture and limited success rate. By recession and papilla loss. A study by Addy using restorative or prosthetic techniques, and Hunter reported that irrespective of the contact point can be lengthened apically, manual or power tooth brushing, over or reducing open embrasure and creeping of abusive brushing or force applied interdental gingiva. [2, 36-39] significantly harm the gingival tissues. Orthodontic Approach These traumatic oral hygiene procedures Diastema reduction and creeping of should be identified early and discontinued gingival tissue towards the interdental space to allow re-epithelialization and restoration can be achieved by conventional of papilla. Usage of flat trim toothbrush orthodontic movement of adjacent teeth that bristle, end-rounded filaments, rubber creates new contact point. In conjunction bristles interdental cleaner are with orthodontic treatment, interproximal recommended to reduce gingival abrasion. reduction of enamel is one of orthodontic Improper use of dental floss can damage the approach to achieve contact point. Inter interdental papilla. Traumatic interproximal Proximal Reduction of enamel on triangular

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 5 Vol.4; Issue: 2; April-June 2019 Divyanshu Jamwal et.al. Treatment of Interdental Papilla: A Review crown will convert contact point to a Among several minimally invasive broader contact area thereby reducing Black techniques proposed, the injection of Triangles. Normally 0.5-0.75mm enamel is various fillers and biological preparations removed to prevent occurrence of open has been studied for papilla reconstruction. embrasures. A study by Livas mentioned Hyaluronic acid (HA) is a large molecule, that a maximum of 50% of interproximal non-sulphated glycosaminoglycan present in enamel can be removed without causing connective tissues of skin and cartilage. dental risk. By application of gentle, Physiologically it contributes to tissue continuous pressure on tooth, coronal hydrodynamics, by binding to water to movement can be seen resulting in closure provide elasticity and stability resulting in of interdental space. This effects alterations tissue regeneration and healing. It is non- within the supporting structures and causes immunogenic, biocompatible and changes in bone level and the soft tissue bacteriostatic which enhances its clinical contours, thereby creates new papillae. significance. Initially it was used as dermal Cardaropoli et al. presented a study filler, but the recent findings have suggested evaluating a combined approach of its use to treat interdental papilla loss. HA in orthodontic-periodontal treatment for tissues is digested by macrophages in blood reconstruction of the interdental papillae or lymphatic system and broken HA reaches between upper central incisors, bloodstream to get disintegrated in liver for demonstrating that the soft tissues adapted excretion. HA is eliminated through urine. to the new emergence profiles during HA has antioxidant property by which it intrusion of the teeth as the interproximal scavenges reactive oxygen species that spaces were reduced. [40-42] further helps in the regulation of immune Repeated Scrapping of the Papilla response implying its anti-inflammatory Recreation of papillae which were properties. HA’s this anti-inflammatory previously destroyed by necrotizing response makes it ideal for biomedical gingivitis is done by repeated curettage usage. Chemical modified hyaluronic acid every 15 days for 3 months. This preparations degrade slowly than biological instrumentation induces a proliferative HA extending its clinical efficacy by 6-12 hyperplastic inflammatory reaction of the months. Such preparations are used as fillers papilla. Approximately 9 months after initial which are usually manufactured from treatment, regeneration of interdental animal sources and more recently papillae was observed. Few papillae showed Streptococcus species of bacteria was used complete regeneration, while others did not to extract gel form of hyaluronic acid which respond to the periodic curettage. was chemically cross-linked with butanediol Yanagishita et al. observed improvement of diglycidyl ether, stabilized and suspended in interdental papillae in a patient undergoing neutral phosphate buffered saline. A study supportive periodontal therapy. All the by Becker et al, aimed to evaluate the patients undergone initial periodontal efficacy of commercially available therapy for periodontitis, including oral hyaluronic acid gel to eliminate deficient hygiene instruction, scaling and root papillae. A total of 14 GBTs were treated by planing. Patients were asked to stop the use injecting HA gel 2-3mm apical to the tip of of an interdental brush to allow the the papilla up to 3 times at 3 weeks interdental papillae to recover. A gradual intervals. The study concluded that it is improvement was observed in recession of possible to enhance papillae that do not the interdental papillae over a period of entirely fill the interdental space with an several years together with coronal regrowth injectable hyaluronic gel and the results of the gingival margin. [43,44] were promising, even after 25 months and Tissue Volumizing no relapse was observed. A series by Lee et al. evaluated the clinical efficacy of using

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 6 Vol.4; Issue: 2; April-June 2019 Divyanshu Jamwal et.al. Treatment of Interdental Papilla: A Review hyaluronic acid gel on enhancing interdental significant improvement in recreation of papilla deficiency using radiographic interdental papilla at 6 months post HA gel assessment and it reported that when HA injection. However, according to Tanwar was repeated up to 5 times every 3 weeks and Hungund, though, HA is biocompatible and the post follow up period of 6 months, and safe to use, with no evidence of there was a significant improvement in cytotoxicity, HA is associated with allergic interdental papilla reconstruction with reactions and patients should be warned of contact point and bone crest reaching 6mm. this possible treatment side effect. [45,46,7,9] Mansouri et al. assessed the efficacy of using HA gel for reconstruction of Surgical approach: interdental papilla. It was reported that Papilla Recontouring application of HA gel successfully treated In the presence of gingival interdental papilla deficiencies in a 6 enlargement, the excess tissue should be months period. A clinical trial by Awartani eliminated to remodel the soft tissue and Tatakis examined effects of using architecture in the case of drug-induced injectable, non-animal based, HA gel in hyperplasia, idiopathic gingival hyperplasia reconstruction of interdental papilla loss. etc., a gingivectomy may be performed. (Fig This study concluded that there was a 4)

Fig 4- Pre and post-operative pictures of Gingivectomy. (Department of Periodontology, Bharati Vidyapeeth Dental College and Hospital, Pune)

Papilla reconstruction is applied on the palatal aspect, to support Several case reports have been published the papilla. Han and Takie (1996) proposed regarding surgical technique for an approach for papilla reconstruction reconstruction of deficient papilla (Beagle (semilunar coronally repositioned papilla) 1992 Han and Takie 1996, Azzi et al. 1998). based on the use of free connective tissue However, the predictability of the various graft (Fig 5) procedures has not been documented, and no data are available in the literatures providing information on the long-term stability of surgically regained interdental papillae. Beagle (1992) described a pedicle graft procedure utilizing the soft tissues palatal of the interdental papilla. [47,48]

Technique Fig 5- Han and Takei ‘Semilunar Coronally Advanced Flap’ A split thickness flap is dissected on the [47] palatal aspect of the interdental area. The flap is elevated labially, folded and sutured Technique to create the new papilla at the facial part of A semilunar incision is placed in the the interdental area. A periodontal dressing alveolar mucosa facial to the interdental

Galore International Journal of Health Sciences and Research (www.gijhsr.com) 7 Vol.4; Issue: 2; April-June 2019 Divyanshu Jamwal et.al. Treatment of Interdental Papilla: A Review papilla and a pouch like preparation is unpleasant scarring after healing. Nordland performed into the interdental area. in 2008 described Microsurgical technique Intrasulcular incision is made around the for augmentation of the interdental papilla. mesial and distal half of the two adjacent The above techniques showed that teeth to free the connective tissue from the using an interposed subepithelial connective root surface to allow a coronal displacement tissue graft can regenerate lost interdental of the gingival papillary unit. A connective papilla, and the reconstructed papilla tissue graft, taken from the , is placed remained stable and without any clinical into the pouch to support the coronally signs of inflammation for 4 years after positioned interdental tissue [49,50] surgical procedure, but the long-term Azzi et al. (1998) described a technique, in survivability and the technique sensitivity which envelope type flap was prepared for involved in the surgery to considered. In the coverage of connective tissue graft. [47] (Fig case of implant therapy, the absence of 6) inter-implant papillae impairs esthetics. Some attempts have been proposed in the literature to recreate the scalloped and positive architecture of the soft tissue around implants (Palacci et al., 1995). One novel technique consists of buccal dislodgment of a full-thickness flap raised from a site slightly more palatal with respect to the implants. To ensure and stabilize the most coronal position of the flap, the ramp

Fig 6- Azzi et al Envelope flap technique [47] mattress suture technique is performed. This new suturing approach provides a coronal Technique: pulling traction, whereas the palatal flap A crevicular incision is made at the receives compression on its underlying tooth surface facing the interdental papilla layers. After 4-5 weeks, a vestibular to be reconstructed. Subsequently, an scalloped gingivectomy is performed in incision placed across the facial aspect of correspondence to the vestibular surface of the interdental papilla and an envelope type the abutments to create a positive split thickness flap is elevated into the architecture of the gingival margin. [51-53] proximal site as well as apically to and beyond mucogingival line. A connective Papilla preservation tissue graft is harvested from the tuberosity Various flaps have been described area, trimmed to adequate size and shape for the preservation of interdental papilla. and placed under the flap in the interdental papillae area; the flaps are brought together A] Conventional Papilla Preservation flap and sutured with the connective tissue graft. Takei et al. in 1985 introduced conventional In 2001, to increase the volume of the papilla preservation technique. Sulcular interdental tissue additional to the flap incisions are given around each tooth and described in the aforementioned study, Azzi with the lingual/palatal flap a semilunar et al. (2001) associated an autogenous bone incision is made across each interdental graft from the region of the maxillary papilla that dips apically from the line tuberosity with a connective graft tissue angles of the tooth so that the papillary from the region of the palate. Conventional incision line angle is at least 5mm from the techniques are unpredictable due to small gingival margin allowing the interdental working spaces and limited blood supply to tissues to be dissected from the the area. Vertical releasing incisions can lingual/palatal aspect so that it can be further jeopardize vascular supply and leave elevated intact with facial flap. [54] (Fig 7)

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Fig 7- Conventional papilla preservation flap technique. [54]

B] Modified Papilla Preservation Flap aspect. An oblique incision is given along Cortellini et al. (1995) introduced a the defect associated papilla from the new modification of conventional papilla gingival margin at the buccal line angle of preservation flap. It was brought in practice the involved tooth to reach the mid as Minimally Invasive Surgical Technique. interproximal portion of the papilla of the A horizontal incision is given buccally on adjacent tooth. The oblique incision is the interdental space at the base of the carried forward intrasulcularly in the buccal papilla. The papilla is elevated toward the aspect of the teeth adjacent the defect and palatal aspect. It is mostly suitable for thick extended to partially dissect the papillae of interdental papilla in wide interdental the adjacent interdental spaces allowing the spaces. [55] (Fig 8) elevation of a buccal flap with 2-3mm exposure of alveolar bone. [56] (Fig 9)

Fig 9- Simplified Papilla Preservation Flap [56]

D] The “Whale’s tail” technique Bianchi and Basseti in 2009 introduced a technique known as Whale’s Fig 8- Modified Papilla Perservation flap [55] tail technique. This is a surgical technique C] Simplified Papilla Preservation Flap that preserves the interdental tissue by Simplified papilla preservation guided tissue regeneration. It is used for the technique is suitable for narrow interdental treatment of wide intrabony defects in the spaces (≤2 mm). This technique is a esthetic zone that involves the elevation of a modification of Modified papilla large flap from the buccal to the palatal side preservation which is given by Cortellini. allowing accessibility and visibility of the The horizontal incision given in Modified intrabony defect and to perform GTR while Papilla Preservation flap is replaced by an maintaining interdental tissue over grafting oblique incision and placed on the buccal material. The reflected flap looks like a tail of a whale, hence the name Whales Tail aspect of the interdental papilla, and the [57] papilla is elevated towards the palatal technique. (Fig 10)

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